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Special Tests: Cervical Radiculopathy, Cervicogenic Headache, and Canadian C-spine Rules Audio

Special tests for cervical radiculopathy, cervicogenic headache, and Canadian cervical spine (C-spine) rules. The Wainner's Clinical Prediction Rule for Cervical Radiculopathy, Spurling's Compression Test, Upper Limb Tension Test, Distraction Test, Shoulder Abduction Test, Cervical Flexion, and Rotation Test, and Canadian C-spine Rules for "red flags". The reliability, specificity, sensitivity, validity, safety, and screening for neck pain, headaches, and radiculopathy.

Special Tests: Cervical Radiculopathy, Cervicogenic Headache, and Canadian C-spine Rules

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Wainner's Clinical Prediction Rule for Cervical Radiculopathy

Less than 60° of rotation on the affected side

Radiculopathy and cervicogenic headache are relatively common symptom clusters correlated with chronic and acute cervical spine dysfunction. For example, long hours behind a desk with forward head postures, and whiplash syndrome following a car accident, can result in symptoms that match these diagnoses. Often patient complaints include the feeling of a "pinched nerve" with lateral bending (lateral flexion) or axial compression. Or, they may mention that their headache and neck symptoms tend to get worse at the same time, and sometimes "massage" aids in reducing their symptoms. In more serious cases nerve root compression (for example, with herniated disk) can result in radicular symptoms and muscle weakness. Both cervical radiculopathy and cervicogenic headache can be reliability assessed using the special tests covered in this course. For more serious issues that may imply a need for emergency care, the Canadian C-spine rules have demonstrated high sensitivity and utility in clinical practice. For example, fear of moving the neck and significant muscle weakness should imply a recommendation to visit an emergency room.

The special tests that demonstrate an acceptable level of accuracy for the cervical spine focus on just a few diagnoses, and likely miss the most common cervical complaints. Radiculopathy, cervicogenic headache, and screening for necessary imaging are covered in this course. These diagnoses do not include the common complaints of mechanical/postural chronic neck pain. Clinical experience and a comprehensive subjective examination will likely dictate whether the testing below is necessary. The most accurate tests, based on available research, were chosen for each potential diagnosis.

 Generally, cervical radiculopathy tests are more specific than sensitive. For example, the Wainner's Clinical Prediction Rule (CPR), a cluster of radiculopathy tests, demonstrates very high specificity but low sensitivity (12). This is a little odd considering this CPR includes the Upper Limb Tension Tests (ULTTs) which have high sensitivity. Alternatively, the ULTTs exhibit relatively high sensitivity and low specificity (4, 6, 12, 15, 16 - 19), which may imply they are a useful screen for diagnoses such as "nerve pain", "radicular symptoms", or "nerve root irritation". Note, Wainner's CPR is more accurate than the use of axial compression, distraction, or lateral bending tests alone.

 Cervicogenic headache is a diagnosis that licensed human movement professionals should give more attention to. The prevalence of cervicogenic headache is relatively common; however, it seems these patients are not referred to licensed human movement professionals often. There is one particular test that demonstrates high sensitivity and specificity for this diagnosis (21 - 25).

 Canadian C-spine Rules are important for identifying "red flag" conditions (spinal cord injury, emergent need for spine surgery, muscle weakness (neurological motor loss, etc.) that should be referred out for imaging and additional diagnostics before intervention is attempted. These rules are highly-sensitive, which is ideal for a screen of this type (26 - 30)

 recommends that all clinical professionals are aware of these special tests (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.). The 

 for cervicogenic headache, are particularly effective for identifying two diagnoses that may be best treated by movement professionals. Additionally, a copy of the Canadian C-spine Rules should be easily accessible for identifying cervical patients with "red flags" who should be referred out for additional testing.

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, accuracy (specificity, sensitivity, reliability, etc.), how we chose the tests in each special test course lessons, and best practice recommendations:

Additional Special Tests for the Cervical Spine:

Special Tests: Upper Cervical Spine Instability and Vertebrobasilar Insufficiency (VBI)

Course Description: Special Tests: Cervical Radiculopathy, Cervicogenic Headache, and Canadian C-spine Rules

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, how we chose the tests in these lessons, and best use, check out:

The special tests that demonstrate an acceptable level of accuracy for the cervical spine focus on just a few diagnoses, and likely miss the most common cervical complaints. Radiculopathy, cervicogenic headache, upper cervical spine instability, vertebrobasilar ischemia, and screening for necessary imaging are covered in these courses. These diagnoses do not include the common complaints of mechanical/postural chronic neck pain. Clinical experience and a comprehensive subjective examination will likely dictate whether the testing below is necessary. The most accurate tests, based on available research, were chosen for each potential diagnosis.

 Generally, cervical radiculopathy tests are more specific than sensitive. For example, the Wainner's Clinical Prediction Rule (CPR), a cluster of radiculopathy tests, demonstrates very high specificity but low sensitivity (12). This is a little odd considering this CPR includes the Upper Limb Tension Tests (ULTTs) which have high sensitivity. Alternatively, the ULTTs exhibit relatively high sensitivity and low specificity (4, 6, 12, 15, 16 - 19), which may imply they are a useful screen.

 Canadian C-spine Rules are important for identifying "red flag" conditions that should be referred out for imaging and additional diagnostics before intervention is attempted. These rules are highly-sensitive, which is ideal for a screen of this type (26 - 30).

Introduction

The patient assumes a sitting position with a neutral cervical spine.

The patient is asked about resting symptoms, and the examiner moves behind the patient.

The patient is asked to laterally flex the cervical spine to the side of concordant symptoms.

If lateral flexion results in concordant pain, especially referred symptoms down the arm, the test is positive.

If lateral flexion does not result in symptoms, the examiner applies over-pressure by combining lateral flexion and compression of the cervical spine.

If over-pressure results in concordant pain, especially referred symptoms down the arm, the test is positive.

Diagram of the foramen of the cervical spine

Spurling's Compression (Foraminal Compression) Test

Tests are performed in the supine position and resting symptoms are assessed.

Tests begin with depression and stabilization of the scapula and reassessment of resting symptoms (17).

Wrist extended and ulnar deviated, fingers extended

Shoulder Abducted to 110º and externally rotated to 90°

Shoulder internally rotated and abducted 10° or more

Tests are positive if there is a considerable restriction in extensibility and radiated symptoms

Tests may be sensitized by adding cervical lateral flexion:

If symptoms increase with contralateral cervical flexion; more indicative of cervical radiculopathy.

If symptoms decrease with ipsilateral cervical flexion; more indicative of cervical radiculopathy.

Note: Every text I referenced had a different set of instructions for these tests, including different joint actions, different order of steps, and different numbering/titling of the various nerve biases. For this reason, the tests were named by the nerve being tensioned, steps were ordered based on common practice, and only tests referenced in the research were used. The order of steps likely matters less if symptoms are reassessed with each step.

Upper Limb Tension Tests

The patient assumes a supine position with the examiner at the head of the table.

The patient's resting symptoms are assessed.

The examiner grips the patient's head around the occiput (occipital shelf of the neck) and underneath the chin. A chin cradle grip, commonly used for joint manipulations, is appropriate.

A traction/distraction force is applied, pulling the head longitudinally to lengthen the neck and "open the foramen".

Pain and patient comfort is respected, and the patient's symptoms are reassessed in the tractioned position.

Several repetitions should be used to confirm any change in symptoms with a traction force.

A positive test is a reduction in concordant pain or referred pain.

Note, an increase in pain during traction should also be noted. Although this sign is not conventionally considered a positive test, it is indicative of cervical involvement in symptoms.

Cervical Distraction Test

Cervical Spine

Wainner's Clinical Prediction Rule (CPR) for Cervical Radiculopathy

Shoulder Abduction Test (also known as the Relief Test or Bakody's Sign)

The patient assumes a sitting position with a neutral posture.

The patient is asked to place the hand on their affected side on top of their head.

The test is positive if placing the hand on top of the head reduces the patient's symptoms.

Additional Tests

Cervical Flexion Rotation Test for Cervicogenic Headache

Patient assumes a supine position, with the examiner standing at the head of the patient.

The patient actively flexes the neck as far as they can.

The examiner then moves the patient's head into full flexion with end range rotation.

Patient's symptoms are assessed at end range in both directions.

The test is positive if concordant signs are replicated, or if cervicogenic headache symptoms coincide with a reduction of more than 10° range of motion during this test.

Cervicogenic Headache

Diagram of the cervical vertebrae

Red Flags

Cook, C., & Hegedus, E. J. (2008). Orthopedic physical examination tests: an evidence-based approach.

Dutton's Orthopaedic examination, evaluation, and intervention

Bertilson, B. C., Grunnesjö, M., & Strender, L. E. (2003). Reliability of clinical tests in the assessment of patients with neck/shoulder problems—impact of history. 

De Hertogh, W. J., Vaes, P. H., Vijverman, V., De Cordt, A., & Duquet, W. (2007). The clinical examination of neck pain patients: the validity of a group of tests. 

Sandmark, H., & Nisell, R. (1995). Validity of five common manual neck pain provoking tests. 

Scandinavian journal of rehabilitation medicine

Shah, K. C., & Rajshekhar, V. (2004). Reliability of diagnosis of soft cervical disc prolapse using Spurling's test. 

SPURLING, R. (1944). Lateral rupture of the cervical intervertebral discs: a common cause of shoulder and arm pain. 

Tong, H. C., Haig, A. J., & Yamakawa, K. (2002). The Spurling test and cervical radiculopathy. 

Uchihara, T., Furukawa, T., & Tsukagoshi, H. (1994). Compression of brachial plexus as a diagnostic test of cervical cord lesion. 

Viikari-Juntura, E., Porras, M., & Laasonen, E. M. (1989). Validity of clinical tests in the diagnosis of root compression in cervical disc disease. 

Wainner, R. S., Fritz, J. M., Irrgang, J. J., Boninger, M. L., Delitto, A., & Allison, S. (2003). Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. 

Shabat, S., Leitner, Y., David, R., & Folman, Y. (2012). The correlation between Spurling test and imaging studies in detecting cervical radiculopathy. 

Anekstein, Y., Blecher, R., Smorgick, Y., & Mirovsky, Y. (2012). What is the best way to apply the Spurling test for cervical radiculopathy?. 

Clinical Orthopaedics and Related Research®

Thoomes, E. J., van Geest, S., van der Windt, D. A., Falla, D., Verhagen, A. P., Koes, B. W., … & Vleggeert-Lankamp, C. L. (2018). Value of physical tests in diagnosing cervical radiculopathy: a systematic review. 

Vanti, C., Bonfiglioli, R., Calabrese, M., Marinelli, F., Violante, F. S., & Pillastrini, P. (2012). Relationship between interpretation and accuracy of the upper limb neurodynamic test 1 in carpal tunnel syndrome. 

Journal of manipulative and physiological therapeutics

Legakis, A., & Boyd, B. S. (2012). The influence of scapular depression on upper limb neurodynamic test responses. 

Nee, R. J., Jull, G. A., Vicenzino, B., & Coppieters, M. W. (2012). The validity of upper-limb neurodynamic tests for detecting peripheral neuropathic pain. 

journal of orthopaedic & sports physical therapy

Ghasemi, M., Golabchi, K., Mousavi, S. A., Asadi, B., Rezvani, M., Shaygannejad, V., & Salari, M. (2013). The value of provocative tests in diagnosis of cervical radiculopathy. 

Journal of research in medical sciences: the official journal of Isfahan University of Medical Sciences

Wainner's Clinical Prediction Rule for Cervical Radiculopathy (12)

Davidson, R. I., Dunn, E. J., & Metzmaker, J. N. (1981). The shoulder abduction test in the diagnosis of radicular pain in cervical extradural compressive monoradiculopathies. 

Hall, T., & Robinson, K. (2004). The flexion–rotation test and active cervical mobility—a comparative measurement study in cervicogenic headache. 

Hall, T. M., Robinson, K. W., Fujinawa, O., Akasaka, K., & Pyne, E. A. (2008). Intertester reliability and diagnostic validity of the cervical flexion-rotation test. 

Ogince, M., Hall, T., Robinson, K., & Blackmore, A. M. (2007). The diagnostic validity of the cervical flexion–rotation test in C1/2-related cervicogenic headache. 

Rubio-Ochoa, J., Benítez-Martínez, J., Lluch, E., Santacruz-Zaragozá, S., Gómez-Contreras, P., & Cook, C. E. (2016). Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review. 

Bravo Petersen, S. M., & Vardaxis, V. G. (2015). The flexion–rotation test performed actively and passively: a comparison of range of motion in patients with cervicogenic headache. 

Bandiera, G., Stiell, I. G., Wells, G. A., Clement, C., De Maio, V., Vandemheen, K. L., … & Dreyer, J. (2003). The Canadian C-spine rule performs better than unstructured physician judgment. 

Stiell, I. G., Clement, C. M., McKnight, R. D., Brison, R., Schull, M. J., Rowe, B. H., … & MacPhail, I. (2003). The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. 

Stiell, I. G., Wells, G. A., Vandemheen, K. L., Clement, C. M., Lesiuk, H., De Maio, V. J., … & Brison, R. (2001). The Canadian C-spine rule for radiography in alert and stable trauma patients. 

Michaleff, Z. A., Maher, C. G., Verhagen, A. P., Rebbeck, T., & Lin, C. W. C. (2012). Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. 

Desai, S., Liu, C., Kirkland, S. W., Krebs, L. D., Keto‐Lambert, D., & Rowe, B. H. (2018). Effectiveness of Implementing Evidence‐based Interventions to Reduce C‐spine Image Ordering in the Emergency Department: A Systematic Review. 

Bibliography

Questions, comments, and criticisms are welcomed and encouraged